Patient Consent for Care & Treatment

This Consent Form is provided by Empowering Healthcare Services and its affiliated subsidiaries, FusionCare and Empowering Medical Group. Empowering Healthcare Services is dedicated to providing comprehensive, patient-centered medical care and support services. Together, Empowering Healthcare Services, FusionCare, and Empowering Medical Group are committed to maintaining high standards of quality care, patient privacy, regulatory compliance, and compassionate healthcare services for all patients served.

Our clinicians use a variety of evidence-based, individualized treatment approaches to meet each patient's unique needs. We believe individuals are experts in their own lives and encourage active participation in the treatment process. Treatment practices, goals, and any limitations of the treatment plan will be discussed openly throughout the therapeutic relationship to support informed decision-making and collaborative care.

This consent is intended to support and protect the health, safety, and overall welfare of our patients. It is our responsibility to ensure appropriate care and treatment are provided when necessary while recognizing and respecting each individual's right to autonomy and control over their own body. By signing this consent, the patient acknowledges and authorizes treatment.

All information provided will be treated as confidential and will not be disclosed without the individual's consent, except where disclosure is required or permitted by law. The service's electronic systems incorporate established network and software security protocols, including encryption, to protect and maintain the integrity of confidential patient information.

I hereby consent and authorize Empowering Healthcare Services, FusionCare, and Empowering Medical Group to provide medical care and treatment deemed necessary and appropriate for the diagnosis and treatment of my physical and mental health conditions.

Thank you for choosing Empowering Healthcare Services. This document is intended to inform you of our policies, State and Federal Laws and your rights. Our clinicians use a variety of evidence-based and individualized approaches to serve each client. Our office can be reached by phone 470-433-2223 or email @ info@empoweringhealthcareservices.com.

HIPAA (Health Insurance Portability and Accountability Act of 1996)

HIPAA is a federal law that mandates privacy requirements and patient rights regarding using and disclosing your Protected Health Information (PHI) in connection with treatment, payment, and healthcare operations. HIPAA requires Empowering Healthcare Services to provide a Notice of Privacy Practices. The law requires that we obtain your signature, acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, they contain important information about your rights, and we ask that you review them carefully. When you sign this document, it will represent an agreement between us.

You can restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but we shall honor this agreement if we do. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

In regard to your health information, you have certain rights and responsibilities:

• To request a copy of your medical record and other health information
• Ask for a summary of your health information when requested for a reasonable, cost-based fee
• Request health information corrected that you think is incorrect or incomplete
• Request to be contacted in a specific way (home or office, phone) or to send mail to a different address
• Ask us not to use or share certain health information about you for treatment, payment, or our operations
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer
• You can ask for a paper copy of this notice at any time
• You can complain to our office if you feel we have violated your rights
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights

You have choices and can tell us your choices about what we share:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

How we typically use or share your health information:

• We can use your health information and share it with other professionals treating you.
• We can use and share your health information to run our practice, improve your care, and contact you when necessary
• We can use and share your health information to bill and get payment from health plans or other entities

Confidentiality and Emergency Situations

Your verbal communication and clinical records are strictly confidential except for; (a) information shared with consultants, (b) information (diagnosis and dates of service) shared with your insurance company to process your claims, (c) information you and/or your child or children report about physical or sexual abuse then, by Georgia State Law, (d) where you sign a release of information to have specific information shared.

• If you provide information that informs you are in danger of harming yourself or others, information necessary for case supervision or consultation when required by law will be provided
• If an emergency situation arises for which the client or their guardian feels immediate attention is necessary, the client or guardian understands to contact the emergency (911) for those services
• EHS clinicians will follow those emergency services with standard counseling and support to the client or the client's family.

Financial / Insurance Practices

Services we provide to you are billed directly to your health insurance plan. Our agreement with the insurance provider necessitates sharing relevant information about the services we offer you. We must provide a clinical diagnosis and additional clinical information, such as treatment plans, summaries, or copies of entire clinical record. In such situations, we try to release only the minimum necessary information for the requested purpose.

You may revoke this agreement in writing at any time. That revocation will be binding unless we have taken action based on it or unless your health insurer imposes obligations to process or substantiate claims made under your policy.

By signing this form, I understand that:

• You consent to our use and disclosure of your protected healthcare information as relevant services are provided
• We are required by law to maintain the privacy and security of your protected health information
• We will promptly let you know if a breach may have compromised your information's privacy or security
• We must follow the duties and privacy practices described in this notice and give you a copy
• We will not use or share your information other than as described here unless you tell us we can in writing. Let us know in writing if you change your mind.